Provider Demographics
NPI:1013030766
Name:AWONIYI, WILATRA (DDS)
Entity Type:Individual
Prefix:
First Name:WILATRA
Middle Name:
Last Name:AWONIYI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 BELTLINE RD SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-5549
Mailing Address - Country:US
Mailing Address - Phone:256-353-0410
Mailing Address - Fax:256-353-0649
Practice Address - Street 1:2046 BELTLINE RD SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-5549
Practice Address - Country:US
Practice Address - Phone:256-353-0410
Practice Address - Fax:256-353-0649
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL39121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000079207Medicaid